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CMS proposed changes to the Physician Fee Schedule transforms how Medicare pays for primary care through a new focus on care management, coordination and behavioral health designed to recognize the importance of the primary care work physicians perform.

“The rule’s primary care proposals improve how Medicare pays for services provided by primary care physicians and other practitioners for patients with multiple chronic conditions, mental and behavioral health issues, as well as cognitive impairment or mobility-related impairments.”

The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in calendar year 2017. These services include, but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, the fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Additional policies proposed in the 2017 payment rule include:

Primary Care and Care Coordination: The rule proposes revisions to payment for chronic care management, including payment for new codes and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions. This proposed change is a significant update to the Physician Fee Schedule and will support primary care when and where patients need it most.

Mental and Behavioral Health: CMS is proposing to pay for specific behavioral health services furnished using the Collaborative Care Model, which has demonstrated benefits in a variety of settings. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also proposing to pay more broadly for other approaches to behavioral health integration services which extends beyond the scope of an office visit.

Cognitive Impairment Care Assessment and Planning: CMS is proposing a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer’s). This is a major step forward for care planning for these populations.

Care for Patients with Mobility-Related Impairments: CMS is proposing to pay physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. This increase in payment will improve quality and access for this vulnerable population.

Increasing payments for routine office visits for treating patients with mobility-related disabilities from $73 to $119.

Increasing payments to geriatricians or family practice physicians treating eligible Medicare beneficiaries by at least 2% for providing all of the care outlined in the proposed rule. In his blog post, Slavitt indicated that these increases could amount to more than 30% over time.

Expanding a diabetes prevention program. CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. CMS’ proposal would allow Medicare Diabetes Prevention Program suppliers, recognized by the Centers for Disease Control and Prevention, to submit claims to Medicare for providing diabetes prevention services. CMS is proposing a process for suppliers to enroll in the program so they can furnish services and bill Medicare as soon as possible after the program becomes effective. “Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy. This is part of our efforts for better care, smarter spending, and healthier people,” said Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer. The proposal is an exciting milestone for prevention and population health.

The program began in 2013 and enrolled beneficiaries in eight states: Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio, and Texas. It is the first from the CMS Innovation Center, which was created by the Affordable Care Act, to be proven successful enough to be elevated from a demonstration and rolled out to the full Medicare program. The ACA allows the CMS to expand programs that prove effective without the approval of Congress.

Another key proposal in the physician fee schedule rule would update the quality measures used in the Medicare Shared Savings Program to protect beneficiaries when accountable care organizations waive the rule requiring patients to be hospitalized for at least three days before Medicare will reimburse care at a skilled nursing facility.

Beginning in 2017, providers can ask to waive the three-day rule if they send patients to nursing homes that carry at least three stars on Medicare’s five-star quality ratings.

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